The Doctor Will See You Now!

New rules making California the first state in the nation to shorten the waiting time for an appointment take effect mid-January

(Sacramento) – New rules go into effect on January 17, 2011, making California the first state in the nation to require that health plan members must be scheduled for appointments within certain time frames. The regulations, approved last January, required each health plan to submit a proposal to the DMHC for complying with the required time standards, receive approval, and begin using the standards within one year of the effective date of the regulation (January 17, 2010).

“While these regulations are not a cure-all for what ails health care, they are a big step forward in improving quality of care by shortening the time a California HMO patient has to wait to see the doctor,” said Cindy Ehnes, Director of the DMHC. “It’s important to note, however, that we are not putting doctors on a stopwatch. The burden of complying with the access standards is on the health plan, not the doctor.”

Not being able to get appointments quickly has been a common complaint at the DMHC’s Help Center, which handles consumer complaints about health plans. A 2009 study found that in Los Angeles, new PPO and HMO patients wait an average of 59 days to see a family practice physician.

Beginning January 17, 2011, health plan members will receive quicker responses to their calls, and will generally have the right to appointments within set time frames.

A member’s call for an appointment will be triaged or screened by a qualified health professional to determine the urgency of the caller’s health condition. The triage service, operating 24 hours a day, seven days a week, must respond to a member’s call within 30 minutes, informing the caller of the length of wait for a return call from the provider. The health plan’s customer service representative must respond to a member’s call within ten minutes during normal business hours.

The regulations specify that the usual waiting time for appointments will be:

Within 48 hours of a request for an urgent care appointment for most services that do not require prior authorization,

Within 96 hours of a request for an urgent appointment for services that do require prior authorization

Within ten business days of a request for non-urgent primary care appointments

Within 15 business days of a request for an appointment with a specialist

Within ten business days of a request for an appointment with non-physician mental health care providers

Within 15 business days of a request for a non-urgent appointment for ancillary services for the diagnosis or treatment of injury, illness, or other health condition

While the law sets these time frames, health care providers can be flexible in scheduling appointments if a longer time frame is appropriate for the member’s health. It must be noted in the member’s record that a longer waiting time will not be harmful to the health of the member. If timely appointments are not available jn geographic areas with provider shortages, a health plan must refer enrollees to available and accessible contracted providers in neighboring service areas. In the case of a preferred provider network, the plan must help enrollees locate accessible providers. The new rules place the burden of compliance on the health plan, not the doctor. A health plan must ensure that it has contracts with a sufficient number of doctors in each geographic area to serve its members. This means that plans must have a strong and varied provider network to enable appointments to be made within the specified timeframes.

The California Department of Managed Health Care is the only stand-alone HMO watchdog agency in the nation, touching the lives of more than 21 million enrollees. The DMHC has helped more than a million Californians resolve their health plan problems through its Help Center. The Department educates consumers on health care rights and responsibilities, and works closely with health plans to ensure a solvent and stable managed health care system.